Clinical Cases

Understanding the Role of Susceptibility in Cases of Cirrhosis of the Liver

liver cirrhosis

Drs. Mohammed Irfan and Navin Pawaskar explore the role of susceptibility in cases of cirrhosis of the Liver. Understanding the symptomatology of the case, the quantum of susceptibility and the miasms, provides much required versatility of case management.

Reprinted with permission from the Indian Journal of Applied Homoeopathy where it first appeared. https://www.jimshomeocollege.com/ijah-publications/

Abstract:

The current study deals with cases of cirrhosis of the liver, particularly non-alcoholic fatty liver disease as that happens to be an important aspect where the exact cause is difficult to determine. The focus remains on understanding patho-physiology and susceptibility and its role in selection of remedy and potency.

Introduction:

Cirrhosis is a complication of liver disease which involves loss of liver cells and irreversible scarring of the liver.

Causes:

There are many causes of cirrhosis including chemicals (such as alcohol, fat, and certain medications),viruses (Hepatitis B and C), toxic metals (such as iron and copper that accumulate in the liver as a result of genetic diseases), and autoimmune liver disease in which the body’s immune system attacks the liver. Non-alcoholic fatty liver disease (NAFLD) refers to a wide spectrum of liver diseases that, like alcoholic liver disease, ranges from simple steatosis, to nonalcoholic steatohepatitis (NASH), to cirrhosis. All stages of NAFLD have in common the accumulation of fat in liver cells. The term nonalcoholic is used because NAFLD occurs in individuals who do not consume excessive amounts of alcohol, yet, in many respects, the microscopic picture of NAFLD is similar to what can be seen in liver disease that is due to excessive alcohol. NAFLD is associated with a condition called insulin resistance, which, in turn, is associated with metabolic syndrome and diabetes mellitus type 2. Less common causes of cirrhosis include unusual reactions to some drugs and prolonged exposure to toxins, as well as cardiac cirrhosis. In certain parts of the world (particularly Northern Africa), infection of the liver with a parasite (schistosomiasis) is the most common cause of liver disease and cirrhosis.

Pathology:

Cirrhosis is characterized by abnormal structure and function of the liver. The diseases that lead to cirrhosis do so because they injure and degenerate liver cells, after which the inflammation and repair that is associated with the dying liver cells causes scar tissueto form. The liver cells that do not die, multiply in an attempt to replace the cells that have died. This results in clusters of newly-formed liver cells (regenerative nodules) within the scar tissue.

Symptoms:

Cirrhosis can cause low grade fever, pain in abdomen mostly hypochondria, weakness,loss of appetite, easy bruising, jaundice, itching, and fatigue.

Diagnosis:

Diagnosis of cirrhosis can be suggested by history, physical examination and biochemical parameters viz., S.Bilirubin, SGOT, SGPT, Alkaline Phosphatase and S.Proteins and can be confirmed by liver biopsy.

Complications:

These include edema and ascites, spontaneous bacterial peritonitis, bleeding from varices, hepatic encephalopathy, hepatorenal syndrome, hepatopulmonary syndrome, hypersplenism, and liver cancer.

Treatment of cirrhosis:

Principles of treatment include:

  • Preventing further damage to the liver
  • Symptomatic treatment and control of biochemical parameters
  • Treating the complications of cirrhosis 4) Preventing liver cancer or detecting it early 5) Organ transplantation.

After having dealt with the clinical study of Cirrhosis of liver, the following illustrative cases will help one understand the relevance of this study.

CASE 1

Mr. S. D. aged 64 yrs, worked as an Accountant in a private firm and stayed with his wife in P.

CHIEF COMPLAINTS

Recurrent episodes of pain in Rt. Hypochondrium Rt. and lt. iliac and hypogastric area since 8-9 months. Followed by stools, chills and fever (102-103° F) and perspiration on trunk and legs. Chills were relieved by covering with 3-4 blankets. He had these episodes once a month and lasted for 1-2 days. Accompanied by Drowsiness++, Low muttering++, App ↓, Thirst – (N), Irritability, Tiredness. H/o taking allopathic treatment for backache in which caused generalized edema.  Three months later he had high grade fever with chills and jaundice and was advised admission at higher centre. Diagnosed as cirrhotic changes in liver with splenomegaly with BPH.

Since then has pain in lower abdomen with urgency for stools but unsatisfactory stools. Stools – hard, sticky, no frank mucus. No pain, no burning, no bleeding.

Before coming for homoeopathic treatment he was under treatment from a Hospital in Chennai.

PHYSICAL GENERALS

  • Well built, stooped shoulders.
  • Hearing – Impaired after jaundice. Buzzing after cold drinks.
  • Perspiration –otherwise scanty, Profuse during fever.  Cravings– sweets3chicken2, meat2, spicy2.

Thermals – Hot patient

Sleep – Disturbed by slightest noise

Dreams Prophetic

On Examination:   Mild  hepatomegaly

LIFE SPACE INVESTIGATION

Patient was a tall old man; stoop shouldered, in his 60s, with a short white beard and well-groomed hair, red and hot eyes with cataract changes in eyes. He is the youngest of 6 children of a Bohra Muslim businessman dealing in food grains in Dhinoj village, in Mehsana Gujarat. He has 1 elder brother and 4 elder sisters. Patient’s father was a very loving gentleman. He was very generous and didn’t demand money from people who had taken loan from him. Whatever people returned he was happy and he even burnt the deed papers so that his sons do not trouble them in the future. His business started declining due to his generosity. Father was nice to his kids and they were provided with whatever they asked for. Mother also was good-natured.

Patient was average in studies and scored around 50% in X Std. He wanted to study further, but the financial situation didn’t permit and even elder brother wasn’t working. Patient took up the responsibility and came to Mumbai to work, after convincing his father. Patient’s brother in law was a partner in a company and he appointed patient as a supervisor. After 3-4 years the company went into losses and closed down. Patient was asked to continue in the company’s office with no work but would be paid. Patient refused as he was not interested in sitting idle and earning “Meri Haddiyanaur badan Haraam ka ho jata” He was very particular and fastidious about work and cleanliness.

Later he got a job as a salesman in a hardware company and took up sales in Gujarat. He would travel alone to various places and get orders. Due to his good communication skills the business flourished. The company asked him to take up the responsibility of entire Maharashtra State. Patient pleaded to continue with Gujarat as it would be difficult to start from the scratch but his request was rejected. So he quit the job. By now he was married and had 3 daughters. He had lost his father and patient felt bad, as he was not able to help his father to have a peaceful life. Elder brother also was not working.

He has a large circle of friends who are his main support in life. Some are his clients while some are good old friends. He easily mixes with new people. The friends bailed him out with financial and moral support when patient’s wife underwent hysterectomy for a uterine fibroid in 2002. Patient was very tense at that period. He has repaid all the dues.  His 2 daughters are married and settled. The 3rd daughter is staying with patient. Elder daughter’s daughter also stays with patient.

INTERVIEW WITH WIFE and DAUGHTER

According to them, the patient was a very mild person. Now has become irritable. Scolds granddaughter for not listening to him. Even talk in loud voice to clients on phone, which was not the case earlier.  here has been a drastic change in his nature after an incident in 2000, which shocked the entire family. His youngest daughter, who was patient’s most “Laadli” eloped and married a Maharashtrian Hindu boy and later called up parents to inform them. Patient’s in-laws esp. mother-in-law was very upset as she was very conservative and was worried about the social stigma. Even patient couldn’t believe and accept that his daughter could do this and had stopped eating anything. Everybody tried to convince her to come back, but she refused. Patient’s friends consoled him and asked him to forgive her, which patient unwillingly accepted. Later the daughter converted to Hinduism as the boy was reluctant to convert to Islam as he was the only son to his parents and he wouldn’t want to leave them alone.

Even now the daughter and son-in-law have a good relation with patient and keep visiting them. Patient invites them during Id. But deep within, he hasn’t recovered and weeps sometimes thinking about it.   And whenever he falls ill with fever he wants everyone to be around him.

Totality

  • F.GRIEF
  • INDUSTRIOUS
  • FASTIDIOUS
  • MUTTERING,FEVER DURING
  • DREAMS-PROPHETIC
  • HOT
  • CR-SWEETS3,MEAT2,Spicy
  • SLEEP DISTURBED-< slightest noise.

The prominent remedies which come up after repertorisation are Sulph, Lach, Lyco, Nuxvom, Phos, Nat Mur. As thermally patient is hot, the list reduces to Sulph, Lyco, and Nat Mur.

If we consider Ailments from grief then Nat Mur comes up prominently but the grief of Nat Mur is after the loss of a loved one but here the grief is of been ditched by his favourite daughter with whom he still maintains a good relation after initial state of disbelief. Although Nat Mur also has action on liver, it causes hepatomegaly and splenomegaly along with depression of spirits or despondency. Its action is on assimilation part of the digestive system hence causing emaciation in spite of eating well. Same is the case with Sulphur which has defective assimilation but has been more useful in chronic alcoholism and ailments from it.Lycopodium stands out as it has a profound action on the liver causing congestion and hypertrophy of liver and digestive system. It is especially suited for ailments which develop gradually, weakening of functional powers and failures of digestive powers and hence suited for chronic hepatitis.

Understanding of susceptibility

  • Onset-gradual
  • Pace-slow
  • Pathology-structural irreversible; as the liver has cirrhotic changes are nothing but fibrotic changes.
  • Miasm- Syco-tubercular. The disease is on the verge of travelling from Sycosis into tubercular which is represented by structural changes and erratic and recurrent fevers but an ongoing process of chronic inflammation.
  • Availability of characteristics at physical level- few
  • Age-old age

Susceptibility: LOW- Moderate

Nat Mur doesn’t cover the rubrics Irritability due to fever, Sleep disturbed by slightest noise and prophetic dreams. Sulph although covers most of the symptoms and is predominantly Psoric in nature. So, Lycopodium was the simillimum. The choice of potency was such that it doesn’t disturb the ongoing process of inflammation but also provides a gentle cure.

50 MILLESIMAL POTENCY

  • Introduced by Dr.Hahnemann as a “renewed dynamisation” in § 161 of Organon of Medicine.
  • Renamed as ‘50 millesimal’ by Pierre Schmidt. Mode of administration: water doses or olfaction
  • Repetition:
    1. in long lasting diseases: daily or every 2nd day
    2. in acute diseases: every 2, 3, 4 or 6 hours.
    3. in very urgent cases: every hour or oftener.

ADVANTAGES:

  1. Minimum chance of violent homeopathic aggravation which can be regulated as desired.
  2. Helps to expedite cure of long standing chronic diseases.
  3. Unfolds maximally the latent dynamic powers of drugs for a rapid and lasting penetration.
  4. Quick judgement of correctness of simillimum helps to avoid unnecessary wastage of time.
  5. Repetition of deep-acting medicines several times a day is possible.

Use of the same constitutional medicine for both palliative as well as curative purpose and thus turning the hopeless incurable cases into the curable ones in the long run whenever possible .

Final prescription was Lyco 0/1 daily doses and later 0/2.

FOLLOW UP:

CHANGES-SUBJECTIVE

  • Was enjoying his work, “kaamkarnemeinsphoortihai.” His episodes of fever subsided.
  • No episode of abdominal pain
  • Was better in terms of his general well being.
  • Vertigo didn’t reappear.
  • Biochemical and structural pathology showed improvement. Although the clinical books mention that cirrhosis is irreversible, here we have seen that dynamic doses of homeopathic medicines can reverse the pathology as well as alter the biochemical parameters as indicated below.

IM PR

ES

SI

ON

Mild hepatomegaly with parenchymal inflmtnand mild

splenomegaly. Lt nonobstructive renal calculi in upper pole with           mild prostatomegalyand s/o cystitis with significant post-void residue.

Liver shows

altered echotexture .Mildly dilated PV. Mildly enlarged spleen Enlarged prostate.

Liver is Shrunken

with no

focal lesions

 Normal in size

No     focal lesions.

Normal in size and

echotexture . No focal lesions.

Normal in size and

echotexture . No focal lesions.

Normal in size and echotexture.

No     focal lesions.

5.2mm lt.renal calculus.

 

DATESGOT

(0-45)

SGPT

(0-45)

Alk.PO4 (15-112)BILIRUBIN

 

                  PROTEINS
TDIT

(5.3-7.8)

ALB

(3.5-5.5)

GLOB

(2.3-3.6)

29/11/0373341663.11.61.56.53.53.0
29/09/0447.223.5119.71.60.90.76.93.13.0
18/12/0467.734.895.42.81.31.57.93.94.0
14/02/0558.836.5130.23.31.61.77.23.3
19/03/0537.627.5176.32.31.01.37.83.64.2
06/07/0540.127.0169.21.80.391.46.13.03.1
21/12/0551.364.2168.23.41.71.77.64.23.4
18/01/0667.748.9144.64.81.63.25.93.42.5
05/05/0681.435.3135.61.71.10.66.73.63.1

UGI scopy (during admission at S hospital for hematemesis andmalena):

13/04/06: Grade IV esophageal varices.

-gastric varices

-multiple superficial gastric? and duodenal ulcers without stigma of bleed.

04/03/07: Grade IV esophageal varices with duodenal ulcer. (S hosp) 13/03/07: Large Grade III esophageal varices. Banding done. (H hosp)

19/03/07: Partially treated esophageal varices. Banding done.

03/04/07: residual esophageal varices. Banding done.

Case 2

A 55 years old widow named Ms. S.S, earns a living by making handicrafts. She has 2 children: 1 son and 1 daughter (but both are not staying with her).

CHIEF COMPLAINTS:

  1. Distension of abdomen, with heaviness and hardness in right Hypochondrium since 4 months but increased since 1 month. Worse after eating and drinking and lying on back. Accompanied by loss of appetite and edema of feet (grade I).
  2. Burning pain in anus since 4 months. Increased since 1 month.

Accompanied with bleeding per rectum of bright red colour. Worse during stool and relieved few hours after stools.

  1. Accompanied with anemia, cachexia, exhaustion and edema.

PHYSICAL GENERALS

Thermals: chilly

Aversion to milk

Tendency to constipation On Examination:

Lean bony skeleton

Malnourished.  Pallor+   weight: 39 kgs

Grade I pedal edema. Ascites.

Investigations:

Hb: 4.8 gm%

USG abdomen:

Cirrhosis of liver, portal hypertension.

TOTALITY:

  1. Bleeding per rectum < during stool
  2. Burning in rectum
  3. Aversion to milk
  4. Lean, thin
  5. Anemia
  6. Chilly patient

Discussion:

If one considers time dimension one sees simultaneous involvement of Liver(cirrhosis), rectum(fissure), blood(anemia) and nutrition(malnourishment).The patient has presented with physical complaints which were more at a structural level  with very few characteristics and absence of symptoms at mind level. So the susceptibility is at low to moderate level. Miasm involved is tubercular to syphilitic.

Common hemorrhagic remedies which are prominently chilly are Nit. acid, Ars Alb, Phos, Nuxvom.

Nitric acid:  Acts on margins of outlets, blood, right side, liver etc. Hemorrhage: easy, bright, of bloody water. On the liver produces congestion, hypertrophy and jaundice. The vitality of blood is destroyed with a broken down, cachectic condition.

Ars.Alb: produces destructive inflammation and ulcerations. By the action on blood it produces anemia and cardiac dropsy. On the liver it produces hypertrophy along with splenomegaly after malarial fever.

Phos: It is a prominent liver remedy which causes atrophy of liver and subacute hepatitis. Great weakness after stool. But the prominent feature is the suddenness of its symptoms. With liver symptoms heart soon begins to fail and death ensues.

Nux Vomica: Abdomen is distended. Tenesmus is attended by smarting burning in rectum which is relieved after stools. Sudden hepatic colic with gall stone colic.

Hence a phase remedy is selected. i.e. Nitric acid 30 3 doses were prescribed as it covers the pathology of hemorrhages, cachexia, liver affections etc.

Follow up:

After 1 week of prescription the follow up suggested the following:

  • No pain in abdomen
  • Bleeding per rectum nil
  • Constipation gradually improved
  • Ascites decreased. 76 cm to 67 cm in three weeks
  • Hb rose to 7.8 in one month

This patient maintained follow ups for almost 9 months and was asymptomatic.

Case 3

This is a case of a middle aged male who presented with only a few symptoms

  1. Dyspnea on exertion
  2. Orthopnea
  3. Jaundice
  4. Edema

But on examination and clinical investigations the following totality could be formed.

  1. Cirrhosis of liver
  2. Pedal edema
  3. Cardiac murmur
  4. Cardiac Failure

The susceptibility could be assessed by understanding the following points:

  1. Absence of characteristics
  2. Low vitality
  3. Involvement of vital organs
  4. One sided presentation

Hence the susceptibility is on a lower side i.e. poor susceptibility.

The miasm involved is Syphilis.

This means that you need to introduce a material dose of a remedy to excite the susceptibility of the individual to produce characteristics or cure the case.

Cardus marinus: The action of this drug is centered in the liver, and portal system, causing soreness, pain, jaundice. Dropsical conditions depending on liver disease, and when due to pelvic congestion and hepatic disease. Cirrhosis with dropsy. When complicated with lung and heart symptoms with expectoration of blood.

Digitalis: Jaundice with heart disease. The main seat of action is primarily heart which is the other way in Cardus. Cardiac muscular failure. Enlarged, sore, painful liver. Cardiac failure following fevers. Cardiac dropsy. Dilated heart, tired, irregular with slow and feeble pulse.

Strophanthus: Main action is on heart and circulation. Sense of lively action and aching, weakness of heart. Swollen dropsical extremities.

Although the repertorisation didn’t indicate the remedy we decided to go with an organ remedy.

This patient was discharged within a week and he maintained good health for about 6 months. The CCF and ascites which were the complications in this case were relieved. However, the chief organ of affliction which was the liver (cirrhosis) wasn’t relieved. Further follow ups were not available.

General Discussion:

In the above cases we have seen 3 examples of different dimensions each representing a different level of susceptibility and hence the logic of selection of different remedies and different posology.

  • As the symptomatology changes from a full fledged multitude of symptoms(case 1)to a phase where only physical symptoms are present(case 2) to a case with full blown pathology but common symptoms as in one sided disease(case 3) the remedy changes from a constitutional remedy to a phase remedy to an organ
  • A judicious and logical use of potency and repetition helps in maintaining health even in pathologically structural irreversible case. For instance, the first case was on homoeopathic treatment for more than 2 years and survived for almost 4 years after the last follow up. In the second case the patient was asymptomatic for almost 9 months till the last follow up. The last case maintained good health with reversal of the complication for almost 6 months till the last follow up.

If we graphically represent the inferences:

  1. Quadrants I and IIEstablishing relation between progress of pathology and expression ofcharacteristics in a case:As the pathology progresses from functional to structural reversible to structural irreversible, the number of characteristics recede and move from a higher plane to a lower plane and manifest as mental and physical characteristics to only physical characteristics to only few or no characteristic. This is a sign that susceptibility (which is the individual’s ability to respond and react to a given stimulus, both internal and external) is diminishing as it is overwhelmed by the ongoing onslaught of the disease force.
  2. Quadrants I and IVSymptomatology remains the guiding force to understand the quantum ofSusceptibility: As the characteristics regress the susceptibility reduces from high to moderate to low. Higher the level of characteristics higher the quantum of susceptibility. Higher the quantum better is the ability of an individual to respond to stimulus by homoeopathic similimum.
  3. Quadrants II and IIIRelation between progress of pathology and shift in miasms: As the pathology moves from functional to structural reversible to structural irreversible, in a majority of cases, a miasmatic shift is observed which moves from Psora to Sycosis to Tubercular to There are transitional phases seen in clinical practice if one closely follows the pathology and its expressions in biochemical parameters and correlates with the symptoms. Case 1, had a transition from Sycosis to Tubercular miasm. Miasmatic shift reflects qualitative change in susceptibility which can be observed at both levels of mind and body. This shift also impacts the ability to respond to homoeopathic similimum and the overall prognosis of the case.
  4. Quadrant IVSusceptibility is the guiding force in selection of posology: As the quantum of susceptibility regresses from high to moderate to low, so does the potency from high to moderate to low and to material doses. Similimum is not just selection of the right remedy but also stimulating the susceptibility with the right dosage. In few cases, (like Case 1) we need dynamic potency like 50 millesimal potency, where ongoing pathology has to be tackled without harming the patient further. In case 2 we used centesimal scale while in the 3rd case with hardly any characteristics and hence low susceptibility we used material doses.

Conclusion:

Understanding the trio of a) symptomatology of the case b) quantum of susceptibility and c) understanding of miasms, provides much required versatility of case management to a homoeopathic physician. The relation between the above 3 points is the key to selection of not only the type of remedy but also potency, repetition and prognostication of a case.

References:

  1. Boericke, William, A handbook of Homoeopathic Materia Medica.
  2. Boger, C M. A Synoptic Key to Materia Medica.
  3. Burt, William H. Physiological Materia Medica.
  4. Clarke, J H. A dictionary of Homoeopathic Materia Medica.
  5. Phatak, S R. Materia Medica of Homoeopathic medicines.
  6. https://www.medicinenet.com/cirrhosis/article.htm#cirrhosis_facts

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About the author

Navin Pawaskar

Navin Pawaskar
M.D.(Hom), MICR(BOM),MHA(USA),CPDM(USA).
JIMS Hospital, Hyderabad.
[email protected]
Mobile: +91 750 62 63 508”

About the author

Mohammed Irfan

Dr. Mohammed Irfan M.D (Hom)-Paeds. Assoociate Professor, Dept of Medicine

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